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Page_____of <br /> S:VvRCB>January 2002 <br /> Secondary Containment Testing Report Form <br /> �*w This form is intendedfor use by contractors performing} <br /> �erivdic testing of USTsecondary conta <br /> ry inment systems- Use the <br /> orm, written <br /> procedures, and <br /> a ropriate pokes of this form to report resultsfo lied toll mthe facr'lity owner/operatoponents tested. The �ltor submittal to the lotcal regulatory agency. <br /> PP <br /> printouts from tests (if applicable}, should be pro l <br /> _9 FAC� '{) 1�ATIO1\� vara of Tasting: August 29,2013 �. <br /> Facility Name: Marigold Shell ---- "�G <br /> Facility Address: 6131 Pacific. Ave.,Stooltton.Ca 95207 <br /> Fhone: (209)95'2-4862 <br /> Facility Contact, Hung Tran 7; <br /> t,�oQ_3_,by Affor <br /> Date Local Agency W Norified of Testing: <br /> Inspector(ifpresent during testing!: — h <br /> dame of <br /> Local Agency pe _ <br /> •-------— 2. TESTING ( <br /> O C i OR ORIVIA TI( <br /> "_'" , <br /> R&D Compliance Testing � I R N M E N� <br /> Company Name: -__ <br /> Technician Conducting Test: Benjamin F.Duncan Jr. X 4WRCB Li4enSed anK Test -P_A{�-i <br /> Credentials: CSLB Licensed Contractor — L5246802-UT <br /> License Type: <br /> Tank Tester + License Nvumber: )0-11203CUr s <br /> Ia� u#actnrer'iraiatin Date Ex ,ires <br /> Comnoncnt(s) ----------- - <br /> N4anufacturer <br /> I S� 1VIiV ARY G-V TEST Sig Tis' <br /> �'-�"�' � Not Repairs' <br /> Repairs Comounent Pass 1 Fail Tested Made <br /> Component Pass Fail iTested Made ' -- <br /> J n ❑ Y <br /> Secondary Pipe#1CD <br /> . � ❑ l ❑ G <br /> Secondary Pipe 42 X ---- <br /> n i n ��- f ❑ ' ❑ ❑ <br /> Secondary Pipe 43 X ❑ <br /> Piping Sump 41 X C. --—— --- ❑ ❑ i L' <br /> Piping Sump 42 X ❑ ❑ '-' -- <br /> Piping Sump#3 x Cl 17 Q <br /> Dispenser Sump#1&2 X p ❑ ❑ ❑ ❑ G <br /> Cl ❑ ❑ <br /> Dispenser SiL-np#3&r4 X ❑ I ❑_ -- - <br /> Dispenser Sump# 5&6 X ❑ C ❑ _ <br /> Dispenser Sump#7&8 _ X ❑ ❑ C3 ❑ <br /> If hydrostatic testi.iig-was performed,describe what was done with the ivater after completion of tests: <br /> Test Fluid Supplied and recovered i-or reuse by,R&D Compliance'resting. <br /> —CERTIFICATION OF TECHNICIA214 RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best'of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: . ._ �-a _ Date:Augt79 2 13 <br />